HISTORICAL DEVELOPMENT

OF MCH/FP/RH CONCEPTS
AND SERVICES
Why MCH

Disciplines in medicine and health were not

able to comprehensively deal with all of
the inter related problems of mothers and
children.
WHO’s four priorities (1948)

 Tuberculosis
 Malaria
 MCH
 Venereal Diseases
 Each Medical Head quarter to include a
medical deputy director
 BUT WHY SPECIAL CARE FOR MOTHERS AND
CHILDREN
 Majority population ( women are about 23% of the total
population and children under 15 years constitute about
47% in developing countries)
 Vulnerable group of population
 Problems of mothers and children are intertwined
 Health problems are avoidable
 “Voiceless”
 Investment in to the future
MCH/RH DEVT CONT’D

 MCH - Eessential component of PHC

( Almata, 1978)
 Where is the “M” in MCH?, Lancet, 1985
 Safe Motherhood Conference, 1987,
Nairobi
MCH/RH DEVT CONT’D

 UNFPA – 1960s
 “Population bombs”, “standing room only ”
 Availability of technologies for reducing
fertility
 Population policies– 1970–80s
 FP programs to restrain Pop growth
MCH/RH DEVT CONT’D

International Conferences (Bucharest,

Mexico)
The Paradigm Shift to RH (1994)
 Radical shift away from technology-based,
directive top-down approaches to program
planning and implementation.
 Possible to achieve the stabilization of world
population growth while attending to people’s
health needs and respecting their rights in
reproduction
MCH/RH DEVT CONT’D

 Recognition of the needs of people in

sexuality and reproduction beyond
fertility regulation.
 Criticism of the over-emphasis on the
control of female fertility
 The advent of the HIV/AIDS pandemic
Prior works on the development of the
reproductive health concept (Fathalla,
1987))

 People have the ability to reproduce and to regulate

their fertility;
 Women are able to go through pregnancy and
childbirth safely
 The outcome of pregnancy should be successful in
terms of maternal and infant survival and well-being;
 Couples are able to have sexual relations free of the
fear of pregnancy and of contracting disease
Successful Pregnancy Outcomes

 600,000 maternal deaths per year

 Lifetime risk of maternal death
 Developed countries: 1 in 1800
 Developing countries: 1 in 48
 Low birth weight infants: 23 million/ year
 Perinatal deaths: 7-8 million/year
 <5 year deaths: 12 million/year
Ability to re produce and regulate
fertility
– Infertility:
 60-80 million couples
– Regulate and control fertility
 23-58 million unintended/mistimed births/ year
 50 million induced abortions/ 20 million unsafe
 120 million couples with unmet need for family
planning
Sexual Relations Free of Fear of
Contracting Disease

 330 million new STD cases/ year

 22 million HIV+ persons
 1 million new cases/ year
Related Reproductive Health
Problems

 Domestic Violence: 20- 50+% of

reproductive-aged women
 Gynecological morbidity: 20- 70% of
reproductive-aged women
Female genital cutting: 100 million women
DEFINITION (ICPD 1994, Cairo)

Reproductive Health: is a state of complete

physical mental and social well being and not
merely the absence of disease or infirmity, in
all matters related to the reproductive system
and its functions and processes.
DEMOGRAPHIC IMPORTANCE OF REPRODUCTIVE
HEALTH

 Growth in number of women aged 15-49 in

developing world:
– 1965: 526 million
– 2025: 1,666 million
 Growth in world population aged 10-14
– 1965: 598.7 million
– 2025: 1,155 billion
RH CARE

Reproductive health care is defined as the

constellation of methods, techniques and
services that contribute to reproductive
health and well-being by preventing and
solving reproductive health problems.
RH RIGHTS
 The rights of couples and individuals to
decide freely and responsibly the
number and spacing of their children, and
to have the information and the means to
do so;
 The right to attain the highest standard
of sexual and reproductive health; the
right to make decisions free of
discrimination, coercion or violence.
Enabling conditions for RH

 Empowering Women and Promoting

Gender Equality and Equity
 Eliminating Discrimination against the
Girl Child
 Ensuring Male Responsibility and
Participation:
 Achieving Universal Education:
OBJECTIVES OF RH CARE

 Ensure that comprehensive and factual

information and a full range of
reproductive health services, including
family planning are accessible,
acceptable and convenient for users
 Objectives Cont’d

 enable and support responsible voluntary

decisions about child bearing and methods
of family planning of their choice, as well as
other methods of their choice for regulation
of fertility which are not against the law and
to have information, education and means to
do so
Objectives Cont’d

 meet the changing reproductive health

needs over the life cycle and to do so in
ways sensitive to the diversity of
circumstances of local communities
WHO Program goals for RH (1997)
 Experience healthy sexual development and
maturation and have the capacity for equitable and
responsible fulfillment
 Achieve desired number of children safely and
healthily, when and if they decide to have them.
 Avoid disease and disability related to sexuality and
reproduction and receive appropriate care when
needed
 Be free from violence and harmful practices related
to sexuality and reproduction.
COMPONENTS OF RH CARE

 quality family planning counselling,

information, education, communication and
services
 prenatal, safe delivery and post natal care,
including breast feeding
 prevention and treatment of infertility
 prevention and management of
complications of unsafe abortion
Components Cont’d

 safe abortion services, where not against the law

 treatment of reproductive tract infections,
sexually transmitted diseases and other
conditions of the reproductive system
 information and counselling on human sexuality,
responsible parenthood and sexual and
reproductive health
Components Cont’d

 active discouragement of harmful practices,

such as female genital mutilation
 referral for additional services related to family
planning, pregnancy, delivery and abortion
complications, infertility, reproductive tract
infections, sexually transmitted diseases and
HIV/AIDS, and cancers of the reproductive
system
 SOME REPRODUCTIVE HEALTH INDICATORS FOR
ETHIOPIA (Compare with other countries)

Indicators Estimates

Maternal mortality ratio 673/100000 live birth

Total Fertility Rate 5.4 children/woman

Contraceptive Prevalence Rate 14%

Percentage of attended once by skilled personnel for reasons related to pregnancy 28%

Percentage of births attended by skilled personnel 6%

Perinatal mortality rate 52/1000 birth (2000)

Percentages of live births with low birth weight (WHO&UNICEF, 2000) 12.4%
The Integrated Approach to RH Services

 It addresses a range of client reproductive health needs

 It saves time and money for clients as services are
obtained during a single visit
 A single service provider may offer a range of reproductive
health services
 Clients gain confidence in the service provider
 Client satisfaction with and utilization of services increases
 The coordination and cost effectiveness of services are
improved
 Opportunities to create client awareness of the availability
of other services increases.
 
Challenges of the Integrated
Approach

 Skills in different components

 Workload increased?
 Attitude and motivation of health workers
 Pressure to reach target in individual
component(s)
 Monitoring and evaluation components
 Which components to integrate?
Sexual Health

 The enhancement of life and personal

relations, and not merely counselling and
care related to reproduction and STDs
 The capacity of individuals to enjoy a
satisfactory sexual life without risk, which
does not include procreation as an
indispensable element
Sexual Health

Three basic elements

 A capacity to enjoy and control sexual and
reproductive behaviors in accordance with social and
personal ethic
 Freedom from fear, shame, guilt, false beliefs and
other psychological factors inhibiting sexual
response and impairing sexual relationship
 Freedom from organic disorders, diseases, and
beneficiaries that interfere with sexual and
reproductive functions
Sexuality

 A broad term covering what we physically

are, what we feel and do in relation to the sex
we have, as well as the social rules and
guidelines existing for each gender
– It is the psychological expression of individuals as
a sexual being in a given socio cultural context,
geographic area and historic moment.
Components of Sexuality

 Sensuality
– Awareness and feeling about your own body and other people’s
bodies, especially the body of a sexual partner
 Sexual Intimacy
– Sexual intimacy is the ability to need and to be emotionally close to
another human being and have that closeness reciprocated.
 Sexual Identity
– Sexual Identity is a person’s understanding of who she or he is
sexually including the sense of being male or female.
 Sexual relations
 Sexualization
– Using sex or sexuality to influence, manipulate or control other
people's behaviours including seduction, and withholding sex from
a partner to 'punish' the partner or to get something, offering
money for sex, selling products with sexual messages, sexual
harassment, sexual abuse and rape.
GENDER AND RH

 Gender the socially constructed roles,

activities, and responsibilities assigned to
women and men in a given culture, location,
or time.
 Sex biological and genetic differences
between men and women.
SEX

 Type of genital organs (penis, testicles,

vagina, womb, and breast)
 Type of predominant hormone circulating in
the body (oestrogen, testestrone)
 Ability to produce sperm or ova(eggs)
 Ability to give birth & breastfeed children.
GENDER
 Learned and changes over time
 Functions at the household, community, and national
levels
 Embedded in a society's social, cultural, economic,
and political systems
 Framework which includes not only laws and
regulations but the institutions which enforce or fail to
enforce them
 Gender differences interact with other inequalities
such as race, age, social class, and ethnicity.
Gender Bias

 Gender based prejudice

– Assumptions or beliefs expressed without reason
or justice and which are generally unfavourable
– May lead to physical and psychological harm to
women and men
– Often affects women
Gender Stereotype
 Beliefs that are ingrained in our
consciousness that many of us think that
gender role are natural and so we don’t
question them
 Women
– nurses, housewives, secretaries
 Men
– doctors, household heads, managers
Gender Mainstreaming
 The incorporation of gender issues into the analysis,
formulation, implementation, monitoring of strategies,
programs, projects and activities
 Addresses and helps reduce inequalities between
women and men
 Helps to increase involvement of women in decision-
making process (formal and informal) about social
values, development directions and resource
allocations.
Gender Mainstreaming

 Requires gender analysis

 Permits the identification of women and men
access to benefits and decision-making
 Implies re-evaluation of current policy and
development programs
Gender Analysis

A process of identifying gender specific division of

labour, cultural patterns, access to and control
of/over resources for the purpose of understanding
their implication for the design and implementation of
development projects

– Shows how gender issues are related to development

– Requires accurate and gender disaggregated information
Gender disaggregated information

The basic questions

 Who plays which role in the family, community, society?
 Who does what?
 Who has what?
 Who gets what?
 What factors influence gender arrangement in society?
ICPD-94 and Gender
 Women’s needs and preferences are central to
development
 Women’s health is rooted in social, cultural,
economic, and political systems
 Identification of specific strategies relating to
increasing women’s reproductive choices
 Concern over a range of health conditions covering a
woman’s life cycle
 Recognition of the need for a wider range of high
quality integrated services.
Essential components of population
activities and RH

 Advancing gender equality, gender equity,

and the empowerment of women
 Eliminating violence against women
 Ensuring women’s ability to control their own
fertility
Gender and Health Services

Gender influences:
 The priority given to women’s health services
 Decisions about which services should be offered
 Resource allocation
 How the quality of services is defined and monitored
 The degree to which women participate in decisions
about the above
Assessing gender sensitivity in health
services

Policy Environment
 Rationale for the provision of RH services
– human rights/efficiency/demographic imperative
 Statement of commitment to gender equality
 Legal and/or regulatory barriers which would
affect gender and health
Assessing gender sensitivity in health
services

Programming
 Needs assessments conducted from the view
points of both men and women
 Programs and activities analyzed from a
gender perspective
 Women's groups have been involved in the
planning process
Assessing gender sensitivity in health
services

Resource allocation and financing

 How much money is allocated for what?
 What share of expenditure is devoted to
public services which have been identified as
– reducing the burdens of women
– gender inequalities in health, education, income,
and leisure
Assessing gender sensitivity in health
services

Participation
 Methods of consultation with stakeholders
 Which groups have been represented
Violence against Women (VAW)

Any act of gender-based violence that

results in, or is likely to result in, physical,
sexual or mental harm or suffering to
women, including threats of such acts,
coercion or arbitrary deprivation of
liberty, whether occurring in public or
private life.
Emotional and psychological
 Telling someone s/he is ugly
 Denial of love/ affection/ sex
 Humiliation
 Refusing to help someone in need
 Name-calling, shouting at the person
 Damaging their favorite possessions
 Threatening physical or sexual violent
 Writing threatening letters to someone after s/he
ends relationship
Physical violence
 Slapping, beating, pinching, hair pulling,
burning, strangling
 Threatening or attacking with a weapon or
object
 Throwing objects at a person
 Physically confining (locking in a room or
tying up)
 Ripping off clothes
Sexual violence
 Beating a person to force her/ him to have sex
 Touching a person’s sexual body parts against
her/his will
 Using vulgar and abusive language to coerce
someone into having sex
 Putting drugs into a person’s drink so that it is easier
to have sex with him/her
 Refusing to use contraceptives or condoms
Impact of psychological, physical and
sexual abuse
Fatal outcome
 Death due to intentional injury (murder), suicide, AIDS
maternal death
Non-fatal outcomes
 Mental health
– Low self-esteem
– Sexual risk-taking
– Substance & alcohol abuse
– Anxiety & depression
Impact of psychological, physical and
sexual abuse

Non-fatal outcomes
 Physical health
– Injury
– Disability
– (Blindness, etc.)
– Other physical symptoms
Impact of psychological, physical and
sexual abuse

Non-fatal outcomes
 SRH/STI
– Gynecological/ urological problems
– Unwanted pregnancy
– Pregnancy complications
– Miscarriage
– Unsafe abortion
– Pelvic inflammatory disease
– Sexual problems
Application of Human Right to sexual
and Reproductive Health

Right to life
– Promote Safe motherhood and advocate against
Maternal Mortality and Morbidity
– Infanticide, Genocide, and Violence
Right to Liberty & Security of the Person
– Protection of women and children from sexual
abuse
– Female genital mutilation
Application of Human Right to sexual
and Reproductive Health

Right to be Free from all forms of discrimination

– Discrimination with regard to access to sexual
and reproductive health services
– Discrimination which denies legal protection
against violence
– Campaign for laws which prohibit discrimination
against women and their effective enforcement
Application of Human Right to sexual
and Reproductive Health

Right to Information and Education

– Youth access to information and education
– Programmes which enable service users to make
decisions on the basis of full, free, and informed
consent
– Discourage programmes which do not give full
information on the relative benefits, risks, and
effectiveness of all methods of fertility regulation
Application of Human Right to sexual
and Reproductive Health

Right to be Free from Torture and Ill Treatment

– Protection of women and children from sexual
exploitation, prostitution
– Protection of women and children sexual abuse,
coercion in any sexual activity, and domestic
violence
– Legislation which prohibits abortion on the
grounds of rape.
Application of Human Right to sexual
and Reproductive Health

The right to privacy

- All sexual and reproductive health care
services should be confidential

- Women have the right to autonomous

reproductive choices
Application of Human Right to sexual
and Reproductive Health

The right to freedom of thought

- Freedom from the restrictive interpretation
of religious texts, beliefs, philosophies and
customs as tools to curtail freedom of
thought on sexual and reproductive health
care
Sexual and Reproductive Rights

 The right to choose whether or not to marry to found

and plan a family
 The right to decide whether or when to have children
 The right to health care and health protection
 The rights to the benefits of scientific progress
 The right to freedom of assembly and political
participation
READINGS
 United Nations (1994). Program of Action adopted at the
International Conference on Population and Development,
Cairo 5-13, September 1994.
 AbouZahar C. WBI Core Course on Population, Reproductive
Health and Health Reform. Background paper on reproductive
health. September 2000. Washington DC
 Fantahun M. Lecture Notes in RH/MCH for MPH students
(Draft) 2001